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REVIEW ARTICLE published guidelines, train the staff on it, assess
Intrahospital transport
policies: The contribution of
the nurse
Despoina G. Alamanou 1, Hero Brokalaki 2
1. RN, MSc, PhD(c), 2nd Internal Medicine
Department, 417 V.A. Hospital of Athens, Greece
2. Associate Professor, Faculty of Nursing,
National and Kapodistrian University of Athens,
Greece
Abstract
Background: Although intrahospital transports are
performed daily in hospitals, they pose various
risks to patients, which could lead to life-
threatening complications. Nursing care,
significantly, contribute to achieve the above,
although the role of the nurse has never been
studied, separately. The aim of this study was to
analyze the risk factors for complications that
usually occur during intrahospital transports and
describe the role of nursing in intrahospital
transport policies.
Method and Material: We searched electronic
databases Medline, Cinahl, Cochrane Library and
Scirus, for the period 1980-2013, on both original
articles and reviews, selecting and analyzing the
articles related to the issue.
Results: The risk factors for complications during
intrahospital transport are related to patients
illness severity, handling during transport,
inadequate equipment, lack of highly trained staff,
inadequate monitoring and ineffective
communication among staff during transport.
Nurses have an active involvement in intrahospital
transport procedures, as personnel of the sending
and receiving departments or as members of the
intrahospital transport team, following or
upgrading current policy. Nurses can create an
intrahospital transport protocol, based on
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and stabilize patients health condition prior to
transport and improve the overall quality of care
for transported patients.
Conclusion: The risks posed by intrahospital
transports for critically ill patients can be
minimized or even prevented by a well-designed
transport protocol with the effective participation
of the nurse.
Keywords: Critically ill patients, health care,
intrahospital transport, literature review, nursing
care
Corresponding author: Despoina G. Alamanou, 10-12 Monis
Petraki Str, P.O. 11521, Athens, Greece,
Tel: 00306937509784, e-mail:
despina_alamanou@hotmail.com
Introduction
The need for numerous diagnostic or
interventional tests in hospitalized patients
requires, even today, where technological
development is rapid, and their transport into or
outside the hospital.
Intrahospital transport is called the transfer of
patients in the hospital for diagnostic or
therapeutic purposes or their transfer to
specialized units of the hospital.1 This usually
involves moving the patient from an area of the
hospital such as the intensive care unit (ICU), the
emergency department (ED), the operating
theatre department to areas that patients may
not receive the same intensive care. The
reduction or change of care and the movement
itself can become, for the critically ill patients, the
cause for serious complications and put their
health at risk.
In recent years, intrahospital transports have
been extensively studied and described in
literature as risky procedures, especially for
critically ill patients.2 They are associated with
increased incidence of life-threatening
complications, morbidity and mortality,3
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particularly for patients transported outside the
ICU.
The interest of researchers in the last 20 years
has focused on adverse events occurring during
intrahospital transport of critically ill patients, 4,5
the equipment that should accompany the
critically ill during transport,6 and on the
prevention and management of these
complications.
Several professional organizations, including
the Society of Critical Care Medicine (SCCM), the
American Association of Respiratory Care, the
European Society of Intensive Care Medicine
(ESICM), the Study Group for Safety in Anesthesia
and Intensive Care (SIAARTI), the Australasian
College for Emergency Medicine and very recently
the Socit de Ranimation de Langue Franaise
(SRLF), the Socit Franaise d'Anesthsie et de
Ranimation (SFAR), and the Socit Franaise de
Mdecine d'Urgence (SFMU) have published
guidelines for the performance of intrahospital
transports.7 Hospitals all over the world
developed intrahospital transport policies, based
on the above. However, not every hospital in all
countries does follow these guidelines, due to lack
of resources or highly trained personnel.
Transporting a critically ill patient within the
hospital creates a challenging and highly stressful
work environment, even for experienced
physicians and nurses.8 Nurses, in every day
clinical practice, deal with critically ill transported
patients, who need holistic nursing care and their
role can be multifunctional, since they participate
in almost every part of patients care having
different and complex responsibilities.
For example, a nurse providing care in the
Radiology Department must facilitate the required
diagnostic testing and simultaneously provide the
surveillance necessary to detect physiological
changes signaling the need for intervention, like
activation of a Medical Emergency Team.9 Nurses,
working in ICU, must provide high-quality nursing
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HEALTH SCIENCE JOURNAL
care, constant monitoring and prepare the
critically ill patient for transport outside of the
secure environment. Nurses working as members
of the intrahospital transport team should provide
qualitative, continuing health care and vigilance
for the occurrence of complications during
transport. In addition, as members of clinical
departments in the hospital, they are also
responsible for preparing and stabilizing patient
before sending for transport and after admitting
patient to destination department. Therefore, the
assumption of these responsibilities should be
undertaken by appropriately trained nurses and
other personnel, because as Fanara10 poses in a
study, the critically ill patients, prepared and
accompanied by inappropriate personnel are a
dangerous combination.
The purpose of this review was to analyze the
risk factors for complications and highlight the
contribution of the nurse in intrahospital
transport policies, followed to prevent these
complications.
Searches of four large electronic databases,
Medline, Cinahl, Cochrane Library and Scirus,
were conducted for data collection, on both
original articles and reviews. The search was
limited to articles published between the years
1980 and 2013. The articles related to our
interest, were selected and analyzed, founding
that very few data exist on the role of the nurse in
intrahospital transport policies, all of which are
mainly reference points in studies of relevant
issues.
Risk factors for complications during
intrahospital transports
Intrahospital transport complications were
recorded for the first time in the early '70s, where
a study by Taylor11 found that 84% of patients
with severe heart problems, who were
transported, had arrhythmias and more than half
of them required immediate intervention.
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The process of intrahospital transport is
considered to adversely affect the patients
condition, whose body has reduced physiological
reserves to counteract the alterations induced by
the environmental changes.12 The frequency of
complications could reach 76.1% 13 and they could
be short or long term or even require immediate
intervention.
The complications that occur during
intrahospital transport of critically ill patients, as
shown in Table 1,12 are usually from circulatory
and respiratory systems, or from other systems
and complications derived from the intrahospital
transport equipment. The risk factors for these
complications are complex and related to patients
and severity of their illness, equipment and
malfunction of the devices, poor communication
between staff that prepare and accompany the
patient, inadequate monitoring of patient during
transport and insufficient documentation of
intrahospital transport procedure.14
Therefore, the existence of an intrahospital
transport protocol or plan is, obviously, not just
useful, but important. Especially, when critically ill
patients are transported, a standard and well
known healthcare policy is required.
Nurses should be aware of the risk factors for
complications and act accordingly to transport
policies to avoid the occurrence of unexpected
outcomes.
Specifically, changes in the condition of the
patient may occur due to preexisting health
conditions, changes of environmental conditions,
or may follow the course of the severe illness
from which the patient suffers. The process of
intrahospital transport may cause minor
complications such as a harmless hemodynamic
instability, or critical incidents that may put
patients life at risk. Interruption of vasopressor
drugs infusion, pain, inadequate oxygenation,
reduced dose of sedative drugs, changes in the
distribution of body fluids due to movement,
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stress and anxiety are common causes of
hemodynamic instability. In a study, investigating
the effects on circulatory and respiratory systems
of oxygens therapy discontinuation during
intrahospital transports was found an important
decrease in partial pressure of oxygen in blood
(PaO2) and in saturation of oxygen in blood
(SaO2), increased heart rhythm and arrhythmia.15
Thus, the nurses that prepare critically ill patients
for transport should consider the continuation of
intravenous therapy and oxygen administration
during transport, at the same levels, as if patient
was in the ICU, as an extremely important matter.
Regarding the process of intrahospital
transport, patients health condition may be
adversely affected by various external factors
when moving from the bed. The changes in
patient's position can cause alterations in flow of
liquids and medicines, disconnection of
intravenous catheters, extubation or deregulation
of the portable ventilator, causing respiratory
distress. In addition, changes in location can result
in pain and movement or removal of drainage
tubes. Therefore, nurses and paramedical
personnel that are responsible for moving
patients on stretcher for transport should be
trained in the proper movement of critically ill
patients, who are under mechanical ventilation
and have intravenous and other catheters, in
order to avoid previous complications.
Inappropriate handling of the vehicle with
which the patient is transported is another
influencing factor. Sudden speed changes and
sudden changes in the direction of stretcher may
result in increased intracranial pressure or cause
pulmonary edema, due to movement of blood to
the head and chest, or cause reduction of blood
supply to vital organs and cerebral ischemia, by
suddenly moving blood to the abdomen and legs.
Finally, any shock and vibration can cause patient
pain, tissue damage, and hemodynamic
disturbances. Careful and soft handling is needed
to avoid the above complications.
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Patients may experience hypothermia during
transport. The main factors for the occurrence of
hypothermia is exposure to areas with low
temperature, interruption of heating of infusive
fluids, lack of insulation blankets and absence of
heated humidifiers of ventilators. Patients
temperature should be measured before
transport and cautions must be taken, such as
extra blankets and continuous heating therapy.
Noises, to which patients are exposed during
transport, being outside of the safe environment
of clinic, may disturb their orientation and cause
confusion, anxiety, fear or even convulsions. For
this reason, patients that are awake and able to
understand us should be informed for their
transport and the possibility of noises appearance
during its performance. In any other
circumstances, ear shields could be used if not
contraindicated.
Equipment used during transport is the most
common risk factor for complications. A study
observing the most frequent adverse events
during intrahospital transports showed that 45.9%
of them were related to equipment, 26.2% to the
patients condition, 25.8% to lines and 2.2% to
other factors.15 Moreover, a study conducted in
Brazil to assess complications during intrahospital
transport of patients on mechanical ventilation
showed that 7.1% of complications were related
to equipment, 7.1% to personnel of the transport
team and 85.8 % to patient and the severity of his
condition.16 Therefore, additional attention must
be paid regarding the equipment. Firstly, when
placing the equipment on stretcher, before
transport, make sure that is secure and stable.
Secondly, during transport, try not to make
sudden movements that can throw the equipment
on patient, causing injuries. After transport,
before putting patient back to bed, beware for the
patients tangling with the equipment which could
lead to disconnection of lines and tubes or
injuries.
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Regarding the personnel involved in patients
transport, the creation of an intrahospital
transport team is necessary for safe transfers in
hospitals. However, this team is insufficient if it
does not consist of properly trained and qualified
personnel. All staff involved in intrahospital
transports need to know how to use the
equipment accompanying the patient, be able to
intervene directly in acute events and properly
interpret the monitoring data. A relevant study
concluded that the use of a specially trained
transport team can reduce the rate of adverse
events during intrahospital transports.17
Inadequate monitoring of a patient during
transport is also a major risk factor. Significant
deficiencies in special equipment may increase
the likelihood of complications. The critically ill
patient should receive the same level of
monitoring as if was in the ICU. Thus, any
unexpected hemodynamic changes will be
properly and quickly identified and managed.
In addition, lack of communication between
staff of the sending and receiving departments of
transport may cause delays in the procedure,
leaving the patient outside of a safe environment
for longer than necessary. Direct communication
of nurses and physicians of sending and receiving
departments prior to transport about the critically
ill will reduce time delays. Also, the transport
team should contact the receiving department
prior to leaving the ICU and then inform the ICU of
the expected time of return.
Finally, lack of documentation of all
transactions carried out during transport is an
obstacle to the effective evaluation of the
outcome, since it does not reflect the actual
implementation of the process. Specifically,
everyday transports documentation should be
kept and evaluated in order to identify possible
mistakes and correct transport tactics.
Nurses contribution in intrahospital transport
procedures
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Intrahospital transport guidelines published,
worldwide, include information about decision
making prior to transport, the personnel involved
in transports, the equipment used in preparation
and stabilization of patient, monitoring during
transport and evaluation of the outcome.
Health care policies for transported patients,
used in any hospital, should include all the above
information, depending on the particularities of
each country or health formation. Moreover, the
role of each specialty involved, as well as the role
of the nurse, should be also described, in all parts
of the existing protocol.
Nurses have an important role in each and
every part of intrahospital transports, since they
daily ensure the continuous and holistic provision
of care to all patients.
Although international guidelines for
intrahospital transport are known for almost two
decades, there are many hospitals where
guidelines are not used in every day practice and
transport policies are not developed. However,
since the decision for transport is taken, an
organized and detailed plan for intrahospital
transport procedure should be available to run.
Decision making
The first and most important step in preventing
intrahospital transport complications is the
decision whether the transport should be done or
not. The risk benefit consideration of its
outcome and the search for alternative solutions
to avoid transport should be the first thought of
health care professionals. According to the
findings of an old study, when technology was not
as developed as today, the outcome of diagnostic
tests, in 76%, does not lead to a change in therapy
within the first 48 hours, which makes us wonder
whether those tests that require transport should
be carried out.18
The anxiety of health professionals, related to
increased responsibility for the transported
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patient and awareness of transport complications,
led to studies calculating the risk in relation to
benefit through specially designed cards and
charts.19 Their goal was the decision for
intrahospital transport to be based on a complete
evaluation of patients health condition, in order
to be done with maximum safety.
Nurses participate in making the decision to
transport, along with medical and paramedical
personnel. They evaluate the health condition of
the patient, who should be haemodynamically
stable in order to cope with the difficulties of
transport and suggest possible alternative ways
for patient to have the diagnostic test, for
example chest x-ray in the bedside of patient,
avoiding the necessity for transport.
Intrahospital transport policy
In such cases, where there are no transport plans
available, highly trained nurses contribute by
building a basic policy for intrahospital transport
performance. They know the allocated equipment
and the equipment deficiencies of the nursing
departments, the personnel and its training, the
way transports conduct in everyday clinical
practice, in the facility of their employment and
the correct actions for a successful transport.
Nurses have the necessary clinical skills to create a
detailed protocol (plan), consistent with the
conditions of the hospital, and also based on the
international guidelines, regarding the personnel
involved in transports, the appropriate
equipment, the preparation procedures and the
evaluation of the outcome.
Personnel
Transporting a patient into a hospital, usually,
includes passing through hallways, elevators and
other areas that are unpleasant environments for
an ill person, because of temperature alterations,
noises, and many people, visitors, or hospital
employees passing near the patient. It is,
therefore, important, even for non-ICU patients,
to be transported by well-trained personnel, who
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would know how to move without delays, protect
patients from harm and inconvenience that could
lead to complications and maintain patients
dignity and respect through the crowded areas
during transport.
Regarding the critically ill, apart from the
above, it is also important for the transport team
to care for the continuation of the provided
treatment, detect possible physiological changes
and be ready to intervene if needed.
According to published international
guidelines, the intrahospital transport team
should consist of minimum two persons, the nurse
who has the responsibility of the patient or a
nurse specialized in intensive care, trained in CPR,
and a trained bearer. When the patient is under
mechanical ventilation is recommended to be
accompanied by pulmonologist trained in
cardiopulmonary resuscitation. Patients who are
intubated and have many intravenous or arterial
catheters and drains should be accompanied by
two or three additional people,20 an nurse, an
emergency room technician and an intensivist (or
anesthetist) for patients who are
haemodynamically unstable and may require
immediate intervention.
Trained nurses not only participate in
intrahospital transport team, but also educate
unqualified personnel in managing emergent
situations and crises during intrahospital
transports. In particular, the nurse presents the
protocol to personnel, explain why it is important
to implement the plan in every transport and help
staff understand the plan by answering their
questions. The nurse, also, trains the intrahospital
transport team in equipment use, maintenance
and control of devices, performs regular exercises
to improve practice and rewards the zeal and
dedication of personnel, in order to feel allies in
the completion of safe transports and not just
executive bodies. Moreover, regular updates and
reassessments would be important for personnel
that do not involve in transports very often.
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Nurses should also promote the training of the
new staff by having them accompany the
transport team to learn about the issues
surrounding the process and the care that is
required to maintain the safety of the patient and
the holistic nature of the transport.
The greatest benefit of using this team is
patients safety during transport and reduction of
complications appearance frequency. A relevant
study showed that patients who were
accompanied by a specialized transport team had
15.5% rate of complications compared with the
overall rate which touched 75%.17
Equipment
Table 2 shows a list of necessary equipment for
the transport of critically ill adults suggested by
the published international guidelines.
The devices, which are used in intrahospital
transports, should have specific characteristics. It
is important the equipment to meet the criteria
for a safe transport. The devices that are usually
needed for the transport of a critically ill patient,
like monitors, oxygen cylinders or material trolleys
are bid, heavy, not easy to carry, always
connected with power source in the ICU or other
departments, and they are rarely moved from
their position. It is not possible the same devices
to be used for a transport, where they should be
on patients stretcher, in motion. For example,
devices without a broad base are unbalanced and
they can easily fall on stretcher when moved, or
devices that are not resistant to hardship can be
disabled due to an unexpected striking on a wall
during transport. The characteristics that the
intrahospital transports equipment should have
are shown in table 3.
In addition, the necessary technical equipment
should be entirely dedicated to intrahospital
transport procedures.21 According to Warren 3
they should definitely include a recording of vital
signs (blood pressure, pulses, temperature, breath
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rate) and an ECG monitor, a pulse oximeter and a
defibrillator, in order all hemodynamic changes to
be accurately and quickly detected and managed.
Nurses, experienced in intensive care, suggest
the use of specific equipment in intrahospital
transports of critically ill patients. They train the
new staff or the intrahospital transport team in
their proper use and ensure the equipments
services and replacement when needed.
Preparation and intrahospital transports
procedures
Preparation for intrahospital transport includes
specific necessary procedures that should be
completed before, during and after transport.12
Nurses have an active involvement in every part
of this process. Table 4 summarizes the most
important of these procedures that nurses
achieve for a safe transport.
As personnel of the sending department
nurses take the decision for transport along with
the medical team, prepare patients appropriately
for transport, maintaining the provided
treatment, as oxygen therapy and intravenous
solutions, prepare the documentation of patients,
which should accompany them and correctly
update the transport team for patients condition,
destination department and type of the required
examinations. They communicate with the
receiving department, informing them for the
expected time of the arrival. They, also, call
additional staff for transport team, when
necessary, due to patients health condition and
receive patients after transport, ensuring
continuity of care and stabilization of their
condition. Nurses, on this position, are also
responsible for the daily charging of the
equipment and checking it for proper operation
and dysfunctions. This action has to be done after
the end of every transport as well, to ensure that
damage has not occurred, as this could
compromise the next transport. In addition,
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batteries should be checked for charge status
prior to their use in a transport.
During transport, nurses as members of the
intrahospital transport team, secure the
equipment on stretcher and provide holistic and
continuing care to the patients during their stay
outside the secure environment. They vigilante for
unexpected complications, such as disconnections
of lines and pathophysiological changes in their
health condition, through monitoring and ensure
the availability and renewal of materials in
stretchers transporting patients. After transport,
nurses record encountered events and
interventions needed.
After the completion of the transport, nurses,
as personnel of the destination department,
receive patients from transport team, continuing
the provided care, get updated on their health
condition and any adverse events encountered
during transport and deliver patients to the team
after the intervention-test, safely.
Evaluation
The completion of the intrahospital transport,
when performed according to an existing
protocol, should be evaluated. The purpose of the
evaluation is to identify problems within the
system, deficiencies in training, human errors, and
unpredictable risk factors of transport, to discuss
unique events where unexpected outcomes
occurred and consider what could have been
avoided.
After the evaluation, improvement
recommendations and further implementation of
them to the protocol are expected. Therefore the
level of the provided care will be continuously
upgraded for critically ill patients in intrahospital
transports.
Nurses, who participated in the creation and
implementation of the transports protocol,
evaluate the intrahospital transports outcome.
Specifically, they, carefully, watch the progress of
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the process, recording complications that
occurred during transport. They communicate
with the personnel on the causes of complications
and propose ways to address them in the future.
They remodel the existing protocol and
recommend improvements by monitoring
international developments and studies.
Conclusions
Intrahospital transports research, internationally,
improved the way they are conducted in hospitals
and reduced the unexpected complications.
However, research and efforts for increased
compliance should continue as Winters 22 study,
recently conducted in Australia, showed that
despite the implementation of guidelines, in 44%
of transports adverse events did occur, the
majority of which could be prevented with careful
planning and better communication between the
personnel.
The participation of qualified, trained nurses
along with the existence of a specific policy in
intrahospital transports, suitable education,
clinical experience in intensive care and
development of communication tools-technics are
the foundation for safe intrahospital transports.
Nurses role is particularly crucial in
intrahospital transports. They assess the health
status of the patient prior to transport, provide
holistic and continuing health care, stabilize and
prepare patient properly and maintain dignity and
respect of patient during transport. In addition,
they ensure compliance with the existing policy
and vigilante for the appearance of unexpected
adverse events during transport and their
effective management. However, this very
important issue has not been purely and
extensively studied by the international scientific
nursing community. Therefore, further
investigation is considered necessary.
With the above in force as Lw and Jaschinski
23
very characteristic wrote a non-transportable
patient, even if in crucial health condition, is just
as unlikely as a non-anesthetizable patient.
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Table 1.Complications of intrahospital transports

Cardiovascular System Changes in blood pressure (usually hypotension)
Tachycardia
Arrhythmia
Cardiac arrest
Pulmonary edema
Respiratory System Changes in respiratory frequency
Pneumonia, aspiration
Airway obstruction
Accidental displacement/Movement of endotracheal
tube
Respiratory arrest
SaO2 reduction
Blood gas alterations
Alterations of acid-base balance
Complications from other systems Increase in intracranial pressure
Pain
Vomiting
Hypothermia
Bleeding
Complications derived from equipment Disconnection/dysfunction of portable ventilator
malfunction Removal/Disconnection of intravenous catheters or
others
Removal of feeding tubes
Shutdown devices (mechanical failure, drop in power,
battery)
Interruption of oxygen supply
Removal of intracranial pressure measuring devices
Patients injury

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Table 2. Necessary equipment for the transport of critically ill adults

Equipment airway management equipment (in the appropriate size
for each patient and a range of sizes, as airway trauma
and swelling may require a smaller tube)
oxygen cylinder (completely filled, so that there is enough
oxygen for the entire duration of transport and 30 extra
minutes in case of a delay)
basic resuscitation medications (such as epinephrine and
antiarrhythmic agents readily available for any heart
attacks and arrhythmias)
additional drugs such as tranquilizers and narcotic
analgesics
a large amount of intravenous solutions and drugs for
continuous intravenous infusion
pumps for liquids and medicines
portable suction (for patients with reduced level of
consciousness, a tracheostomy and/or on a ventilator)
ventilator (which allows for the same ventilatory
parameters as the ICU ventilator, including non-invasive
ventilation modes, and the ability to switch immediately
to manual ventilation through an endotracheal tube or
mask) (Quenot, 2012)

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Table 3. Transports equipment characteristics

Equipment Characteristics Suitable designed
Portable
Simple in use
Resistant to hardship
Small in size
Function with (ac)power and batteries(dc)
Broad base and low center of gravity
Equipped with alarm systems (visual and acoustic)
Placed on special shelf, not on stretcher
Able to work in special areas such as MRI chamber
Easy to control and watch from distance
Ability to record, store and playback data

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Table 4. Before/During/After Transport Procedures

Before transport All staff involved in transport is relieved of other
obligations
Stabilization of patient's condition
Collection and control of equipment used in transport
Collect patients data (medical record)
Connecting patient to monitoring equipment and
control of recording parameters
Reassessment of patient's stability, vital signs,
intravenous and other catheters and drainage
Safe transportation of patient on stretcher, in
comfortable position
Planning of the route to be followed
Communication of the sending department with
destination department to inform those responsible and
to define the arrival time
During transport Follow the easy and short route, planned. Elevators
should be available and secured to avoid delays and
crowds
Means of communication with the destination
department should be available
Continuously checking and recording patients health
condition and the parameters of the devices at regular
intervals, especially if the duration of the transport is
long, to address any complications.
Immediate intervene when needed
After transport Admission of patient at destination department
Reassessment of patient's health condition and control
of equipments operation
Connect patient with the new recording equipment, if
transfers from the stretcher
Detailed update to the monitoring team. The transport
team does not leave the area, if the other team is not fully
prepared to take over
Recording and documentation of all incidents on
specific forms

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